The claim as it was received

Availity clearinghouse · EDI 837P · received 09 Mar 2026 12:46 · 837P_20260309_124934.edi

Received

09 Mar 2026 12:46

Source

Availity clearinghouse · EDI 837P

File

837P_20260309_124934.edi

Interchange control

953310906

Claim control

CCN-0957018577

Storage

az://centene-audit/claims/2026/03/CLM-0000007.edi

Generated from the claim record on request — no file is stored. The storage path above is the hook for real blob storage; once wired it is what would be handed to the agent's document_uri input.

Claim form CMS-1500 (02/12) As received Fax image, 200 dpi EDI 837P 005010X222A1 Remittance EDI 835

What was paid

Check / EFT EFT-20260320-5063

Payment date 20 Mar 2026

Payer Centene

Payee Northside Clinical Laboratory

Payee NPI 1447706632

Billed $7.77

Allowed $7.77

Paid $7.77

Patient responsibility $0.00

The remittance matches the allowable on file. No variance identified.

Line detail

Code	Billed	Allowed	Paid	Should have allowed
85025	$7.77	$7.77	$7.77	$7.77

835 segments

BPR*I*7.77*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260320~

TRN*1*7675271052*1680000000~

DTM*405*20260320~

N1*PR*CENTENE~

N1*PE*NORTHSIDE CLINICAL LABORATORY*XX*1447706632~

LX*1~

CLP*CLM-0000007*1*7.77*7.77**CI*CCN-0957018577*11~